Provider Demographics
NPI:1508087974
Name:MILWAUKEE MIDWEST MEDICAL LAB
Entity Type:Organization
Organization Name:MILWAUKEE MIDWEST MEDICAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:THONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-342-8463
Mailing Address - Street 1:756 N 35TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3360
Mailing Address - Country:US
Mailing Address - Phone:414-342-8463
Mailing Address - Fax:
Practice Address - Street 1:756 N 35TH ST STE 103
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3360
Practice Address - Country:US
Practice Address - Phone:414-342-8463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32931800Medicaid
WI32931800Medicaid